Teaching Case

A primi gravida mother delivered a term female baby elsewhere by vacuum delivery with a birth weight of 2900 grams, and had birth asphyxia and meconium-stained liquor with an APGAR score of 8/10. The baby was referred to our hospital’s neonatal intensive care unit for further management.

Initial imaging evaluation was performed in NICU with cranial ultrasonography, which demonstrated a large heteroechoic collection in the posterior fossa, and the neonate immediately underwent MRI Brain, MRI revealed a large T1 hyperintense T2 hypointense posterior fossa subdural hematoma (SDH) with mass effect on bilateral cerebellar hemispheres, fourth ventricle, brainstem with ascending transtentorial herniation. Dilatation of bilateral lateral and third ventricles was seen secondary to compression of the fourth ventricle.

Right parieto occipital and left parieto occipito temporal thin SDH which extends along the posterior interhemispheric fissure. Thin sulcal SAH hemorrhage is also noted in these regions. Small intraventricular hemorrhage is noted in the dependent occipital horns of lateral ventricles from re-circulation.

Extensive thin SDH was seen along the entire length of spinal canal with effacement of the thecal sac.

CT done for navigation purpose prior to evacuation showed hyperdense hematoma in the posterior fossa, compressing the cerebellum and posterior fossa structures.

Background

The complications of vacuum-assisted birth include cephalohematomas, subgaleal hemorrhages, intracranial hemorrhages, and subdural hemorrhages. According to Williams et al, the incidence of morbidity and mortality from hemorrhagic complications during ventouse delivery is 0.72% and 0.2%, respectively [1].  Only 0.3 per 100,000 live births in the Western population have been reported to have symptomatic posterior fossa subdural hematomas in term newborns [2] and in literature search, Indian population data was not found. The risk factors for posterior fossa hemorrhage include primigravida, breech presentation, difficult delivery, instrumentation, familial bleeding tendency, and vitamin K deficiency [3].

Clinical Perspective

The clinical signs and symptoms of posterior fossa hematoma in newborn are non-specific. Clinically, babies can present acutely in the first few hours of life with features of brain stem dysfunction due to compression or can have delayed presentation after a few days with signs of hydrocephalus [4]. It can mimic hypoxic-ischemic encephalopathy clinically, so prompt imaging is crucial to diagnose this condition based on which further treatment could be initiated. 

Imaging Perspective:

Cranial ultrasonography done through mastoid fontanelle enables proper visualization of the posterior fossa and to raise the initial suspicion of posterior fossa subdural bleeds [5]. Further evaluation with CT or MRI should be done to assess the extent of hemorrhage, mass effect, hydrocephalus, status of brainstem which will plan proper treatment. 

Outcome

Treatment options include surgical and conservative management. Surgical management includes isolated ventriculo-peritoneal (VP) shunting followed by suboccipital craniectomy and evacuation of clot, or immediate suboccipital craniectomy and evacuation of clot. In cases that do not deteriorate clinically, conservative management may be tried with regular follow-ups [2]. In our case, the baby underwent VP shunt placement and suboccipital craniectomy with clot evacuation . Regular follow-ups using cranial ultrasonography and limited sequence MRI have been done for six months, and post-surgically, the baby is doing well.

Take Home Message / Teaching Points

Posterior fossa SDH can occur as a rare complication to vacuum delivery. A prompt call over from the NICU team and careful cranial ultrasonography evaluation is necessary to raise the suspicion of posterior fossa pathologies, and immediate cross-sectional imaging is essential to confirm the diagnosis and to guide proper timely management. It can be managed surgically or conservatively based on the clinical condition and imaging findings.